Return to Emily Friedman home page

A history lesson not learned

by Emily Friedman

First published in Modern Healthcare, May 1, 2006

Four factors stop us from covering the uninsured, but the pressure is mounting

Well, here we are again: another year, another million Americans without health insurance. Although there are major efforts from California to Illinois to Maine to make the situation better, it doesn't take a health policy analyst to notice that these are all state and county initiatives.

As has been true for most of the past 100 years, federal action to ensure that all Americans have coverage is notable by its absence. The three exceptions are Medicaid and Medicare (1965) and the State Children's Health Insurance Initiative (1997), which together have provided protection (to some degree) to tens of millions of people.

Medicaid, however, has been hurt by recent state and federal cuts that have sent as many as 2 million people into the ranks of the uninsured -- with more to come.

It isn't like federal officials haven't tried. Theodore Roosevelt ran for president in 1912 on a platform that promised universal coverage. He lost.

Franklin Roosevelt considered including the concept in the New Deal, but in the end decided against it.

Harry Truman tried to get it enacted; so did Presidents Nixon and Clinton, as well as Sen. Edward Kennedy and former Rep. Wilbur Mills. Nothing happened.

So it seems appropriate to ask why we can't manage to do on the federal level what every other developed nation and many other countries have accomplished. What is stopping us?

Follow the money. There is a great deal of money to be made by not covering the uninsured. It allows health insurers to avoid people who are sick or are likely to be so, and who are therefore more costly than the healthy. It allows providers to do the same in settings outside the emergency department -- and, sadly, sometimes even there. It allows community clinics to reap huge government subsidies for the care of this population, even if that care is automatically limited by the clinic setting. And it feeds a cottage industry of policy wonks who endlessly study the issue, produce reports and try to influence government -- present company included.

Vested interests. Florida State University professor Jill Quadagno has researched universal healthcare for years and has found that whenever it looked like it might happen, a vested interest torpedoed it, whether it was unions in the FDR years or the American Medical Association in the Truman years or private health insurers in the Clinton years. She adds that advocates for universal coverage lacked the power and skill to successfully counter these campaigns. But this factor is so deeply intertwined with the money angle that it is hard to separate the two.

Ideology. Ideologues on the right believe that government has no business funding or even being involved in social services and that the only good solution is a for-profit private-sector solution. Ideologues on the left believe that the only answer is a government-controlled single-payer system. Neither side is willing to give. When a difficult problem requires compromise and understanding of the other guy's view, ideological rigidity is a death blow.

Us and them. James Tallon Jr., president of the United Hospital Fund of New York, was once asked by a reporter why we don't have universal coverage. He replied, "Because the people who make the decisions all have health insurance." Truer words were never spoken. There is a rather large gap between uninsured Jose Gonzalez, who mows lawns, and Congressman Fatbucks, who has lavish taxpayer-funded health insurance.

They may meet (accidentally) at the country club, but it's unlikely that they discuss health policy. The class, race and income tiers of American society have produced a predictable but nevertheless daunting policy problem: The uninsured are overwhelmingly lower-income, disproportionately members of minority groups and disproportionately not native-born.

These are not the barons of Wall Street. As healthcare consultant Roger Evans has written, lack of coverage for the uninsured reflects "the unwillingness of the socio-political system to reward failure." And it is the winners who define failure. As the late songwriter Steve Goodman pointed out, "It ain't hard to get along with somebody else's troubles."

So will it be another hundred years? Not a chance. More and more employers are ceasing to offer coverage.

There are 16 million self-employed people who are increasingly shut out of the insurance market. High-deductible policies are creating millions of severely uninsured workers. Medicaid cuts guarantee further shrinkage of that critical program.

Providers are already beginning to feel the impact of the tidal wave that is coming, and that in some cities and states -- Texas and New Mexico come to mind -- is here. And when enough people who aren't poor and powerless find themselves in the same boat with those who are, we will do what we should have done a hundred years ago.

In the meantime, let us hope that a triumph over these entrenched obstacles comes sooner rather than later. And here's a toast to those physicians, hospitals and clinics who are keeping the uninsured poor alive and, we hope, healthy.

First published in Modern Healthcare, May 1, 2006

Emily Friedman 2006

Return to Emily Friedman home page